This blog is all about the latest and greatest when it comes to medicine and technology. Just in the last decade medicine has changed a lot. For instance, by the end of the year approximately 90% of office-based physicians nationwide will be using electronic health records (EHRs).
How has medicine changed in the last 30 or 40 years? To find out, I talked to three doctors who’ve seen the transition firsthand.
Let’s meet the doctors.
The doctors: Over 100 years of collective experience
- Barbara Bergin, MD, is an orthopedic surgeon at Texas Orthopedics and has been a doctor for 31 years. I highly recommend you check out Bergin’s blog, where she offers tips on keeping your joints healthy using conversational language, humor, and personal anecdotes.
- Damien Howell, PT, DPT, OCS, is a physical therapist at Damien Howell Physical Therapy, and has been practicing for more than 40 years. Howell also blogs. “I started that webpage in 2003 before blogs existed,” he says with a laugh.
- John Errol Asher, MD, is a board-certified infectious disease physician and internist, who began practicing more than 40 years ago before retiring this year.
How doctors who grew up using paper view the EHR
When I asked how medicine has changed, both Dr. Bergin and Dr. Howell brought up the EHR first.
Dr. Bergin’s husband is also a physician. “Both of us lament that the EHR is not conducive for good medical record keeping or knowing what’s going on with our patients,” Dr. Bergin tells me.
Dr. Asher was the only one of the three to not have much opinion about EHRs, because “I don’t even know how to use those electronic records,” he says. “Which is probably why I can’t get a job now. I’m trying to go back to work. I can’t stand not being a doctor.”
EHRs have certainly changed medicine. The doctors talk about the impact of the EHR on the patient experience, record searches, communication between medical facilities, and the paperwork burden.
EHR and the patient experience
Dr. Bergin hates how doctors have to look at the EHR instead of the patient. “I’m only about five years from retirement, and I worry about myself [as a patient],” she says.
“I think we have good doctors but they are faced with having to look at something else rather than at me. That’s going to be the way it is, but it’s just not nice. It’s less conducive to feeling like your doctor really cares.”
EHRs are not user intuitive
I was surprised to hear that one of Dr. Bergin’s main complaints is that EHRs make patient information more difficult to find. “It’s not readily available,” she says. “You have to know the word to search.”
Another problem is that the EHR she uses list information in the order in which it is entered, which doesn’t always correspond to when it was created. So, for example, while she remembers when a lab test was ordered, that doesn’t tell her where to find it in the record because it may have been entered in much later.
Another issue that makes it difficult to find information in an EHR is the user experience. Dr. Bergin says:
She offers an example of a little tornado icon that searches for the next record when you click it: “That’s not what that means to me.”
I don’t think a tornado means “search for the next record” to anyone except one software developer.
The other big problem is the kind of information the EHR stores. Clicking a “yes” or “no” check box next to a predefined field is “not conducive to a doctor telling another doctor what they were thinking,” Dr. Bergin points out.
She says most patient records are simply copied from the previous patient with a few variations and then pasted in, resulting in a “big long sheet of paper” you have to search for information.
By contrast, “The SOAP note was such a beautiful thing,” Dr. Bergin says. “It said what the patient said, what the doctor thinks, and the plan.”
That’s why Dr. Bergin doesn’t use templates, choosing instead to dictate her own notes. “Someday that’ll be impossible to do,” she laments. “New systems are designed to do your billing based on what you dictate, as opposed to what you do.”
EHR portability and accessibility
All the doctors have access to the same EHR within the same hospital system.
“The shortcoming is different hospital systems have different EHRs and I access a different EHR as a physical therapist,” Howell says. “Some have read-only access to competing EHRs.”
“In Richmond, VA we have three hospital systems and each has its own EHR. And they’re not interoperable. You’re back to the fax machines,” he adds.
The lack of portability also frustrates Dr. Bergin. In some hospitals she’s worked in, the ancillary medical centers, radiology, and the lab all use their own EHR.
“When you go to a new doctor the patient has to completely reproduce their entire medical record, including allergies, medications, and surgeries,” Dr. Bergin says. “People are not very good at doing that.”
This unnecessary process is unpleasant for patients. It also means staff have to spend hours on an inefficient and boring task. And transcribing patient handwriting introduces errors that can lead to mistakes that harm a patient’s health.
The EHR paperwork dilemma
When Howell was last working in a hospital, he had a goal of spending an hour with each patient. “But most of that was paperwork,” Howell says. “The documentation was not of quality. I would cut-and-paste to get work done, rather than record meaningful information. That’s one of the reasons I’ve lost more hair.” (Check out 6 Strategies ER Doctors Can Use to Fight Stress.)
Howell says that when he speaks with students who want to become physical therapists, “I spend a lot of time trying to inform them that the future of medicine requires a lot of time being able to document.”
“Good clinicians need to be able to document clearly and concisely but they also need to be good physicians. Sometimes those are different skill sets,” he adds.
The impact of pay for performance
The other big thing driving the increase in paperwork is compliance with Medicare requirements.
However, Howell says the good thing about Medicare paperwork is that it’s consistent. He adds that when it comes to insurance companies, “the most consistent thing about health insurance is inconsistency.”
The thing he likes about Medicare is the move toward the pay-for-performance model, as opposed to fee for service.
“In order to get reimbursed you need to document that you’re providing value to the patient,” he says.
However, it’s frustrating that Medicare doesn’t consider physical therapists physicians and won’t pay for treatment unless a Medicare-qualified physician signs off on the plan of care.
“I have to hound and pester them to sign the the plan of care,” Howell says.
The pros and cons of evidence-based medicine
Better evidence makes it easier to practice evidence-based medicine
“When I started in the 1970’s, we didn’t have controlled clinical trials for physical therapy,” Howell says. “Today we have better clinical research. Across the industry starting in the late 90’s, early 2000’s, evidence-based medicine improved.”
However, while evidence-based medicine has been proven to provide better care, Howell says:
The challenge now is to incorporate evidence-based medicine into patient-centered medicine.
For example, he says, “patients come to me with expectations and goals. They say, ‘I want ultrasound treatment’ or ‘I want to eliminate pain.’ The evidence says that therapeutic ultrasound is not an effective treatment.
They sometimes want an MRI for back pain. But there’s lots of evidence that having an MRI is bad because you progress to surgery before it’s appropriate. It’s not cost-effective. What the patient expects is not always the best choice of care.”
It’s the responsibility of the physical therapist to, “basically do negotiations,” Howell says.
A PT must convince the patient that their expectation of zero pain is not realistic.
“That’s a bit of a challenge nowadays,” Howell says. “It’s a good idea to get an idea of what a patient’s expectations are. The biggest factor in having a good outcome is having an engaged patient. Engaged patients participate in their care, they’re actively involved.”
Howell once worked in hospital that used Gallup employee engagement measures. “Gallup has not developed a patient engagement measure,” and Howell thinks they should.
“Patient satisfaction is not equal to a good outcome. A good outcome is to eliminate the pain, get them to return to work, get rid of an infection, close the wound, an objective sort of measure. When they don’t return because their problem is solved… that’s a good outcome,” Howell says.
How insurance companies are using evidence-based medicine
There is one drawback to evidence-based medicine, however. “More and more insurances are not authorizing certain procedures,” Dr. Bergin says.
For example, she says that many insurance companies refuse to cover knee arthroscopies and meniscectomies in older adults as a rule, no matter what. Even patients who have gone through the most rigorous conservative treatment, including physical therapy, medications, activity modification, etc.
They do this because peer-reviewed studies find that that certain procedures “don’t work.”
However, “when they [the researchers] say the procedure doesn’t work, they mean this procedure doesn’t cure this condition,” Dr. Bergin says.
“But a lot of these procedures improve a patient’s quality of life. Older doctors see this through their career.
So when insurance companies say, ‘Based on the evidence-based medicine this procedure doesn’t work,’ we’re all out here saying ‘Who says this is the case?’ because in our experience this procedure helps these patients,” she adds.
For example, take a 55-year-old patient who “has piece of meniscus flopping around in the knee,” Dr. Bergin says.
“We try cortisone shots, we ask them to lose weight, they take anti-inflammatory drugs, and now they can’t walk, travel, or go to work. We go take that meniscus out and suddenly they’re better. We know they’re going to get arthritis in that knee. But many of these patients, they get relief for years,” she adds.
What insurance companies don’t understand, according to Dr. Bergin, is that “for the most part, doctors don’t do operations that they feel are unnecessary. I deny people all the time.”
Other procedures require peer-to-peer consults before insurance companies will pay for them.
So under this scheme, only people who can afford to pay out of pocket get the higher quality of life these surgeries can offer. Everyone else has to suffer until their joints deteriorate to the point where their insurance will cover a replacement.
“I think we’re going to see more and more of that,” Dr. Bergin says. “Patients will be saddled with having to pay for it.”
Under the ACA, there’s a floor on what insurance companies must cover. I asked if that floor could be raised to include these quality of life procedures. Dr. Bergin was unconvinced.
I asked Dr. Bergin what’s gotten better since she started practicing medicine. She named laparoscopic, x-ray, and scope-guided surgery.
“After surgery, you used to have to keep people in for weeks,” Dr. Bergin says. “Today we understand bowel prep better and we get patients moving faster. We have smaller incisions and better pain management.”
I asked if the pace of innovation was slowing down or speeding up. Dr. Bergin says,
How the doctor/patient relationship has changed
Thanks to the internet, patients come to their appointments with more knowledge than when Dr. Bergin began practicing medicine. “That’s a good thing,” Dr. Bergin says.
I asked if this knowledge has changed her relationship with her patients. and she says no:
How does Howell get patients engaged? “I use Dr. Google or Dr. YouTube to get more engagement.”
For example, when he does gait retraining he shows patients YouTube videos of the appropriate stride length.
“Google is more positive than negative,” Howell says. “It helps with patient engagement.”
Dr. Asher says that when he started practicing medicine, “making money had nothing to do with medicine.”
Today, “making money has become more important. Doctors became more and more money hungry, and became less interested in the patients. And the patients knew that. Not to me. I made house calls, all kinds of stuff. Doctors didn’t do that. I was an old-fashioned doctor.” (Read next: 3 Medical Practice KPIs You Should Be Monitoring, But Aren’t.)
These three different doctors had some similar thoughts on the transformation and evolution of healthcare in the United States over the last 40 years. Despite their promise, EHRs have been a mixed blessing at best. Insurance companies often get in the way of quality care and patient/doctor relationships. And the internet has been an overall boon for patient health, offering valuable information and better engagement.
Are you over 60 and in the medical profession? How do you think medicine changed in the last 30 or 40 years? Let me know in the comments.
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